2012 Blue & Gray Membership Form 

Name___________________________________________________ Age___________ 

Address _______________________________________________________________

City________________________________State__________

Zip __________________ Phone: _________________________E-mail:__________________________________ 

TYPE OF MEMBERSHIP: SINGLE $25      FAMILY $35

IF THIS IS A FAMILY MEMBERSHIP, PLEASE LIST NAMES AND AGES OF OTHER RIDERS: ________________________________________________________________________________________________________________________________________________ 


POINT COUNT STARTS AS SOON AS THE RIDER AND/OR HORSE IS NOMINATED 

Trainer ________________________________________________________________ 

Nominated horses: (1st horse free with single or family memberships, additional horses $5 per horse) 

Horse’s Name __________________________________________________ 

Age _________ Height _______ Color ________ Amount $ _FREE__ 

Horse’s Name __________________________________________________ 

Age _________ Height _______ Color ________ Amount $_________ 

Horse’s Name __________________________________________________ 

Age _________ Height _______ Color ________ Amount $_________

 **Ponies: Please enclose a copy of an USEF, MHSA, or 4-H Measurement card** 

Make all checks payable to the Blue & Gray Circuit.  Mail memberships to: Lori Swanson 2246 Newville Road Carlisle, PA 17015